Healthcare Provider Details

I. General information

NPI: 1073596508
Provider Name (Legal Business Name): JENEEN M MARTIN DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/29/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 S CARPENTER AVE
KINGSFORD MI
49802-4524
US

IV. Provider business mailing address

333 S CARPENTER AVE
KINGSFORD MI
49802-4524
US

V. Phone/Fax

Practice location:
  • Phone: 906-774-2505
  • Fax:
Mailing address:
  • Phone: 906-774-2505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901015240
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: